1. Socio-economic inequalities in the pathway of care for pancreatic cancer James Brown, Jean Adams, Martin White & Mark Pearce Institute of Health & Society Newcastle University

2. Socio-economic inequalities in cancer Most cancers are more common in people living in more deprived circumstances Quinn et al (2001) Cancer trends in England & Wales 1950-1999, London, The Stationary Office

3. People living in more deprived circumstances experience worse survival from cancer Socio-economic inequalities in cancer Quinn et al (2001) Cancer trends in England & Wales 1950-1999, London, The Stationary Office

4. Pancreatic cancer 10 th most common cancer; 6 th most common cause of cancer death in UK –7600 diagnoses/year; 7300 deaths/year Rapidly fatal –13% live 1 year or more –2-3% live 5 years or more Risk factors –smoking, diabetes, obesity –chronic pancreatitis Socio-economic pattern not clear

5. Pancreatic cancer care pathway Symptoms GP Hospital Diagnosis No treatmentTreatment

6. Research questions After controlling for age and gender, are there socio- economic inequalities in incidence? After controlling for age, gender and co-morbidity are there socio-economic inequalities in: –who is receives treatment? –delay from: GP referral to first hospital appointment? first hospital appointment to diagnosis? diagnosis to receipt of treatment?

7. Methods NYCRIS data on all pancreatic adenocarcinomas, 1998-2004, linked to Hospital Episode Statistics Statistical analysis –sex-specific, directly age standardized incidence –logistic regression for receipt of treatment –Cox regression for delays –date of birth –sex –postcode at diagnosis → IMD 2004 –referral date –date of diagnosis –treatment type & date –co-morbidity in year prior to diagnosis → Charleson index –date of death (to June 2006)

8. Results 5 387 cases 52% female 58% diagnosed at age 70+ 87% with Charleson index of 0 25% received treatment Median delay from: –GP referral to first hospital appointment = 8 days –first hospital appointment to diagnosis = 6 days –diagnosis to receipt of treatment = 40 days

9. Socio-economic inequalities in incidence

10. Socio-economic inequalities in treatment Controlled for age, gender & co-morbidity; χ 2 (4)=72.66; p=0.001

11. χ 2 (4)=4.03; p=0.40 χ2(4)=13.90; p=0.008 χ 2 (4)=5.82; p=0.21 Controlled for age, gender & co-morbidity throughout

12. Summary of results Evidence of socio-economic inequalities in: Symptoms GP Hospital Diagnosis No treatmentTreatment

13. Summary of results Evidence of socio-economic inequalities in: –incidence Symptoms GP Hospital Diagnosis No treatmentTreatment

14. Summary of results Evidence of socio-economic inequalities in: –incidence –treatment Symptoms GP Hospital Diagnosis No treatmentTreatment

15. Summary of results Evidence of socio-economic inequalities in: –incidence –treatment –delay from GP to first hospital appointment Symptoms GP Hospital Diagnosis No treatmentTreatment

16. Summary of results Evidence of socio-economic inequalities in: –incidence –treatment –delay from GP to first hospital appointment No evidence of socio-economic inequalities in: –delay from first hospital appointment to diagnosis –delay from diagnosis to treatment Symptoms GP Hospital Diagnosis No treatmentTreatment

17. Major limitations & next steps No control for stage/grade at diagnosis No modelling of effect of various inequalities on survival Any treatment rather than ‘best’ treatment Repeat with –common cancers –better data availability –clear NICE guidelines How and why are there socio-economic gradients in who gets treatment? –observations of consultations & MDT meetings?